Mecklenburg_Well Abandonment_20240918 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well,Contractor Inforpation: WELL ABANDONMENT DETAILS fi Q2e&l f/ 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well gwner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
/r71 wells abandoned:
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NC Well ontractor Certification N /� 7b.Approximate volume of water remaining in well(s):
C�C�, // /✓/ !/ t� FOR WATER SUPPLY WELLS ONLY:
Company Name /� J 7c.Type of disinfectant used: 1
2.Well Construction Permit#: j�/f /
List all applicable well construction pe its(i.e.UIC,County,State,Variance,etc.)if known
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7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑lvig ipal/Public ❑ Neat Cement Grout j,8fintonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Eesidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slung ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier �-"�—
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal (Heating/Cooling Return) ❑Other(explain under 7
4.Date well(s)abandoned:
5s.�Well location: 2024
J e At Y?YOW-eV
Facility/Owner Name Facility ID#(if applicable) 8.Certification: �,�ct:w� ✓ $
0 2917 razz,&v,a�/
Physical Address,City,and Zip e f�j`^�e�f(i�/ i lure of fled Well ntractor or a Owner Date
G- { By signing this form, 1 hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 1C.0100 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
W You may use the back of this page to provide additional well site details or well
` abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
/ 10a. For All Walla: Submit this form within 30 days of completion of well
6a.Well ID#• abandonment to the following:
/ Division of Water Resources,Information Processing Unit,
6b.Total well depth: l d (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: U (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Suooly&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): r (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016